Purpose To report a case of adult-onset Coats’ disease that had worsening of macular edema and progressive macular traction following cryotherapy and repeated intravitreal bevacizumab injections due to formation of a secondary epiretinal membrane which only improved following pars plana vitrectomy and membrane peeling. Observations A 35-year-old male presented with diminution of vision in his left eye and was found to have localized telangiectatic retinal vessels and aneurysmal dilatations with massive exudation and cystoid macular edema. He was diagnosed as adult-onset Coats’ disease and treated with cryotherapy and a concomitant intravitreal injection of 2.5 mg bevacizumab followed by 3 monthly intravitreal injections of 2.5 mg bevacizumab and a single injection of 4 mg triamcinolone acetonide. Partial obliteration of the telangiectatic vessels and aneurysmal dilatations with improvement in surrounding lipid and fluid exudate was achieved, however, this was associated with progressive worsening of macular edema and macular traction due to formation of an epiretinal membrane which only improved following vitrectomy and membrane peeling. Effect of therapy at each stage was evaluated using visual acuity testing, fundus examination, fundus fluorescein angiography, and optical coherence tomography. Conclusion and Importance A secondary epiretinal membrane can develop following treatment of adult-onset Coats’ disease and cause traction especially when combining cryotherapy with bevacizumab injections. Vitrectomy in such cases with membrane peeling may result in improvement of anatomical and functional outcomes.

We report a case of an 80-year-old symptomatic female with severe visceral Armillifer armillatus infestation who presented with complaints of progressively worsening colicky abdominal pain with associated constipation and mild abdominal distension. Imaging workup demonstrated unique radiological features of the parasite including multiple curvilinear opacities, measuring approximately 3 to 6 mm in length, scattered in the lung fields, abdomen, pelvis, and inguinal region. Histologic examination of inguinal biopsies revealed enlarged lymph nodes containing several parasitic pseudocysts. She was managed conservatively and received antihelmintics, with subsequent uneventful recovery. This case emphasizes the importance of meticulous differential diagnoses formulation. In the right clinical scenario, pentastomiasis should be considered in the differential diagnoses of patients with imaging evidence of multiple organ lesions, as a high index of suspicion is needed for the diagnosis of this entity and will help to avoid unnecessary invasive management.

Patient: Male, 21-year-old Final Diagnosis: Antiphospholipid antibody syndrome • cerebral venous sinus thrombosis Symptoms: Blurring of vision • confusion • fever • headache Medication: — Clinical Procedure: Laboratory • magnetic resonance imaging Specialty: Neurology • Ophthalmology Objective: Rare disease Background: Cerebral venous sinus thrombosis (CVST) is a serious life- and vision-threatening condition that can have a variable presentation according to the site of venous occlusion, including mimicking idiopathic intracranial hyper-tension. We report on a patient with primary antiphospholipid antibody syndrome (APS) who presented with papilledema due to CVST that was refractory to medical treatment but responded to optic nerve sheath fenestration (ONSF). Case Report: A 21-year-old man presented with blurred vision of gradual onset and a progressive course for 1 month, accompanied by fever, headache, and confusion. He had a history of lower-limb deep vein thrombosis. Examination revealed decreased vision with bilateral grade IV papilledema. Magnetic resonance venography showed evidence of CVST and laboratory investigations revealed lupus anticoagulant antibodies, antinuclear antibodies, and anti-double stranded DNA antibodies, with hyperhomocysteinemia. The patient did not meet the Systemic Lupus International Collaborating Clinics classification criteria for systemic lupus erythematosus (SLE) nor the new European League Against Rheumatism and American College of Rheumatology SLE classification criteria. He was diagnosed with CVST secondary to APS and hyperhomocysteinemia and treated with acetazolamide, systemic anticoagulation, and vitamins for 1 month, but with no improvement in his ophthalmic condition. He subsequently underwent unilateral ONSF, which resulted in improvement in vision bilaterally that continued throughout a 6-month follow-up period. Conclusions: Papilledema associated with CVST can be the first presentation of APS. When performed in a timely manner, ONSF can save useful vision and lead to improvement in vision in patients with papilledema due to CVST that is refractory to medical treatment.

Botulinum toxin (BT) is a neurotoxin produced by Clostridium botulinum, a gram-positive anaerobic bacterium. Systemic human intoxication from BT following oral ingestion results in acute and lifethreatening muscle paralysis called botulism. BT has a wide scope of therapeutic uses, including conditions associated with increased muscle tone, smooth muscle hyperactivity, salivation, sweating, and allergies, as well as for cosmetic purposes. Several commercial forms of BT are available for medical use, including Botox (onabotulinum-toxinA). Multiple studies have found evidence of an analgesic e fect of onabotulinumtoxinA and demonstrated the benefits of its use for the treatment of various chronic pain disorders. In this review, we provide an update on the use of onabotulinumtoxinA for the treatment of headache disorders.

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Background The chin plays a critical role in the shape, projection, and soft tissue support of the lower face. Osseous genioplasty is a powerful tool in facial rejuvenation as it allows for optimal control of the resulting chin dimensions and improvement in submental and submandibular laxity. Osseous genioplasty can be used alone or in combination with other facial rejuvenation procedures to achieve an optimal result. Objectives We present the senior author’s approach to skeletal analysis of the lower facial third and propose an algorithm that can be used to optimize skeletal support of the overlying soft tissue laxity while maintaining aesthetic facial shape and proportion of the chin. Methods All patients undergoing cosmetic osseous genioplasty for soft tissue rejuvenation of the lower face and/or perioral region with the senior author between 2010-2021 were retrospectively reviewed. Complications including infection, numbness, prolonged ecchymosis were recorded. Results A total of 37 patients underwent cosmetic osseous genioplasty. The average age of the cohort was 44.5 years. Twenty-six patients (70.3%) were female. Eleven patients (29.7%) underwent genioplasty alone. In addition to genioplasty, eight patients (21.6%) underwent orthognathic surgery, five patients (13.5%) underwent platysmaplasty and liposuction, and two patients (5.4%) underwent facelift. The authors propose an algorithm to guide evaluation of the lower facial third to help determine the possible role of osseous genioplasty for facial rejuvenation based on each patient’s unique facial characteristics. Conclusions In properly selected patients, osseous genioplasty can improve lower facial projection, submandibular laxity, and perioral soft tissue support while also optimizing facial shape and proportion.

Conditions that affect dental and periodontal structures receive sparse coverage in the plastic surgery literature, yet a working knowledge of this subject matter is important in certain areas of clinical practice and a fundamental understanding is part of plastic surgery competency tested on the in-service and written board examinations. This 4-part series written to provide plastic surgeons with a working knowledge of dental topics that may be relevant to their clinical practice. This section, Part III, covers inflammatory and infectious conditions of the dentition and related structures, as well as dentoalveolar trauma.

Background Metabolic syndrome (MetS) has been recognized as a global health problem. Concurrent MetS diagnosis in patients with ST-elevation myocardial infarction (STEMI) is becoming increasingly common. Given the paucity of studies on the impact of MetS on treatment outcomes in STEMI patients, the purpose of this study was to evaluate in-hospital mortality in STEMI patients with a concurrent MetS diagnosis undergoing a stenting procedure to treat their underlying coronary artery disease. Method Patients with or without MetS who underwent coronary stenting following STEMI between 2005 and 2014 were identified from the National Inpatient Sample database. Patients' demographics, comorbidities, and outcomes were compared using a t-test and Pearson's Chi-square test. In addition, 1:1 propensity score matching was performed for age, gender, and race. Results Out of 1,938,097 STEMI patients, 5,817 patients with MetS underwent coronary stenting following STEMI and were matched with 5,817 patients with no Mets. MetS group had significantly higher rates of diabetes, hypertension, hyperlipidemia, chronic kidney disease, and obstructive sleep apnea than the no MetS group but lower rates of heart failure and chronic obstructive pulmonary disease. In-hospital mortality following STEMI was significantly lower in patients with MetS (2.5% vs. 7.1%, p<0.001) and remained significant after adjusting for potential confounders (odds ratio (OR) 0.34, 95% confidence interval (95% CI) 0.28-0.42, p<0.0001). Conclusion Concurrent diagnosis of MetS among patients undergoing coronary stenting is associated with a decreased in-hospital mortality risk. The impact of specific MetS components on the observed reduction in mortality remains unclear and warrants evaluation in future studies.